The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

The long-established socialized medicine systems in Britain and Australia are a particularly relevant warning about where such systems end up.

Posts by John J. Ray (M.A.; Ph.D.)

Wednesday, March 17, 2010

Obama hones final health care pitch

Fighting to overcome the impression of high spending and backroom deals, President Obama has honed his health care message to highlight his bill's benefits to consumers — from better Medicare prescription-drug coverage for seniors to guaranteeing insurance regardless of pre-existing conditions.

Supporters say the White House's public relations offensive has breathed new life into Democrats' last-ditch effort to pass the legislation by next week. "So much of his activity in the last few weeks has been around health care," said Karen Davenport, director of health policy at the liberal Center for American Progress. "And I think the power of the presidency drives the stories and makes a huge difference."

After months of drift, with the House and Senate arguing over competing bills, Mr. Obama has taken control of the debate, combining the two bills into a grand compromise, adding Republican ideas and dubbing it bipartisan. On Monday, both he and Democratic leaders said they were very optimistic it would become law.

Mr. Obama took his health care pitch on the road Monday for the third time in one week, traveling to Ohio to again make his case that Congress should ignore the political implications of supporting his bill and vote for it because it's the right thing to do. "The American people want to know if it's still possible for Washington to look out for these interests, for their future," Mr. Obama told a crowd in Strongsville. "So what they're looking for is some courage. They're waiting for us to act. They're waiting for us to lead. They don't want us putting our finger out to the wind. They don't want us reading polls."

Democrats don't yet have the 216 votes required to pass the bills, but House Speaker Nancy Pelosi reaffirmed Monday that they will collect them, dismissing the concerns of some House Democrats about federal funding of abortion, Medicaid funding, Medicare reimbursement rates and the exclusion of protections for illegal immigrants. She called them unfounded. "When we bring a bill to the floor, we will have the votes," she said at a press conference while surrounded by more than a dozen babies and representatives of children's groups that support the health care reform plan.

The yearlong push for health care has seen a series of starts and missteps, culminating with Republican Sen. Scott Brown's surprise victory in a special election to fill the seat of the late Sen. Edward M. Kennedy, Massachusetts Democrat. That victory denied Democrats their filibuster-proof majority in the Senate, and gave backers in both chambers pause.

In a swindle that would make Bernie Madoff look like an amateur, Barack Obama has gotten a substantial segment of the population to believe that he can add millions of people to the government-insured rolls without increasing the already record-breaking federal deficit.

Those who think in terms of talking points, instead of realities, can point to the fact that the Congressional Budget Office has concurred with budget numbers that the Obama administration has presented. Anyone who is so old-fashioned as to stop and think, instead of being swept along by rhetoric, can understand that a budget-- any budget-- is not a record of hard facts but a projection of future financial plans. A budget tells us what will happen if everything works out according to plan.

The Congressional Budget Office can only deal with the numbers that Congress supplies. Those numbers may well be consistent with each other, even if they are wholly inconsistent with anything that is likely to happen in the real world.

The Obama health care plan can be financed without increasing the federal deficit-- if the administration takes hundreds of billions of dollars from Medicare. But Medicare itself does not have enough money to pay its own way over time.

However money is juggled in the short run, the government's financial liabilities are increased by adding this huge new entitlement of government-provided insurance. The fact that these new financial liabilities can be kept out of the official federal deficit projection, by claiming that they will be paid for with money taken from Medicare, changes nothing in the real world.

I can say that I can afford to buy a Rolls Royce, without going into debt, by using my inheritance from a rich uncle. But, in the real world, the question would arise immediately whether I in fact have a rich uncle, not to mention whether this hypothetical rich uncle would be likely to leave me enough money to buy a Rolls Royce.

In politics, however, you can say all sorts of things that have no relationship with reality. If you have a mainstream media that sees no evil, hears no evil and speaks no evil-- when it comes to Barack Obama-- you can say that you will pay for a vast expansion of government-provided insurance by taking money from the Medicare budget and using other gimmicks.

Whether this administration, or any future administration, will in fact take enough money from Medicare to pay for this new massive entitlement is a question that only the future can answer, regardless of what today's budget projection says. On paper, you can treat Medicare like the hypothetical rich uncle who is going to leave me enough money to buy a Rolls Royce. But only on paper. In real life, you can't get blood from a turnip, and you can't keep on getting money from a Medicare program that is itself running out of money.

An even more transparent gimmick is collecting money for the new Obama health care program for the first ten years but delaying the payments of its benefits for four years. By collecting money for 10 years and spending it for only 6 years, you can make the program look self-supporting, but only on paper and only in the short run. This is a game you can play just once, during the first decade. After that, you are going to be collecting money for 10 years and paying out money for 10 years. That is when you discover that your uncle doesn't have enough money to support himself, much less leave you an inheritance to pay for a Rolls Royce.

But a postponed revelation is not part of the official federal deficit today. And that provides a talking point, in order to soothe people who take talking points seriously.

Fraud has been at the heart of this medical care takeover plan from day one. The succession of wholly arbitrary deadlines for rushing this massive legislation through, before anyone has time to read it all, serves no other purpose than to keep its specifics from being scrutinized-- or even recognized-- before it becomes a fait accompli and "the law of the land." Would you buy a used car under these conditions, even if it was a Rolls Royce?

The Slaughter Rule: Yet Another Reason Obamacare Would Be Unconstitutional

As written, the current health care bill before Congress already is guaranteed to face serious constitutional challenges on enumerated powers, 5th Amendment, racial discrimination, and unequal state treatment. Now the White House seems determined to add a whole new reason courts will throw out Obamacare on sight. Director of the Stanford Constitutional Law Center at Stanford Law School and former-federal judge Michael McConnell explains:

To become law—hence eligible for amendment via reconciliation—the Senate health-care bill must actually be signed into law. The Constitution speaks directly to how that is done. According to Article I, Section 7, in order for a “Bill” to “become a Law,” it “shall have passed the House of Representatives and the Senate” and be “presented to the President of the United States” for signature or veto. Unless a bill actually has “passed” both Houses, it cannot be presented to the president and cannot become a law.

To be sure, each House of Congress has power to “determine the Rules of its Proceedings.” Each house can thus determine how much debate to permit, whether to allow amendments from the floor, and even to require supermajority votes for some types of proceeding. But House and Senate rules cannot dispense with the bare-bones requirements of the Constitution. Under Article I, Section 7, passage of one bill cannot be deemed to be enactment of another.

The Slaughter solution attempts to allow the House to pass the Senate bill, plus a bill amending it, with a single vote. The senators would then vote only on the amendatory bill. But this means that no single bill will have passed both houses in the same form. As the Supreme Court wrote in Clinton v. City of New York (1998), a bill containing the “exact text” must be approved by one house; the other house must approve “precisely the same text.”

These constitutional rules set forth in Article I are not mere exercises in formalism. They ensure the democratic accountability of our representatives. Under Section 7, no bill can become law unless it is put up for public vote by both houses of Congress, and under Section 5 “the Yeas and Nays of the Members of either House on any question . . . shall be entered on the Journal.” These requirements enable the people to evaluate whether their representatives are promoting their interests and the public good. Democratic leaders have not announced whether they will pursue the Slaughter solution. But the very purpose of it is to enable members of the House to vote for something without appearing to do so. The Constitution was drafted to prevent that.

At his health care pep rally today, President Obama was introduced by Connie Anderson, sister of Natoma Canfield. The president said it was a touching letter written to him from Canfield that brought him to Ohio. (I'm sure the decision had nothing to do with rustbelt America being the source of Democrats' vote deficit at this point...)

In her letter, Canfield described her battle with cancer how she was forced to give up her health insurance after it became too costly--a sad story, to be sure. But, as Gateway Pundit reports, not likely an entirely true story:

Natoma Canfield is 50 years old. She was diagnosed with cancer 16 years ago. She quit her job or was laid off 12 years ago. She has reportedly held odd jobs cleaning homes the last few years. Natoma was paying $5,000 a year for her insurance but dropped it after it went up to $8,000. She wrote president Obama in December to tell him about it. She was worried she might lose her home. Some people might say she’s lucky to still have a home after losing her job 12 years ago.

Barack Obama came to Ohio today to prop Natoma up on stage with him. But, Natoma Canfield couldn’t make it. She is back in the hospital. (Our prayers for a quick recovery) She is getting cared for despite the fact that she has no insurance. She’s not out on the street. She’s not a statistic like Rep Alan Grayson would have you believe. Natoma is getting the care she needs.

And if Canfield were in favor of real reform, she should encourage President Obama to change the tax code to help insurers properly pool risks instead of additional taxation and government subsidies.

In addition, if the president really wanted to help people like Ms. Canfield, he would encourage the individual ownership rights over health care plans so the American people can maintain control over their health insurance, not employers or the government.

The itsy-bitsy spider climbed up the water spout and apparently bit the Speaker of the House. Ms. Pelosi had a delusional moment the other day, but she was clear on one thing. She never intended to listen to any Republican suggestions regarding the health care bill.

Close observation of the Bipartisan Health Care Summit provided clarity within the first half hour that there was not much bipartisan here. After listening to President Obama, Harry Reid, and Nancy Pelosi, it was obvious that there was no way that they were going to overhaul their 2,400 page (or is it 2,600) health care bill.

I recently enlisted expert advice on the issue. My source was Dr. Bill Cassidy, who doubles as the Congressman from the sixth district of Louisiana and is part of the growing breed of medical professionals that refuse to leave the administration of our country to interests hostile to a cost-effective, patient-oriented, health care system. Dr. Cassidy was elected to Congress in 2008 after spending 20 years serving the uninsured in Louisiana’s public hospital system and teaching at LSU’s outstanding medical school. His specialty is gastroenterology and like many other elected physicians, he still sees patients when he’s back in his district. He is one of the very few people in Congress who truly has first-hand knowledge of those that the omnibus health care bill supposedly seeks to help.

Dr. Cassidy reminded me of an interesting exchange that confirmed President Obama’s utter ignorance of how markets function. Republicans pointed out that the Congressional Budget Office (CBO) analysis stated that premiums would rise under the existing proposals. The President initially insisted that this was not true, but then backtracked, arguing that premiums would go up because the new policies would have additional benefits. What the President doesn’t understand is that for each additional mandate – every one of which increases premiums – more and more consumers would no longer be able to afford the policy. Dr. Cassidy pointed out that the price of health care insurance is not inelastic.

Dr. Cassidy cited Senator Max Baucus as a prime example of the problem with the proposals. Other than the fact that Senator Baucus had to be tone deaf when he stated that the two sides were not really that far apart – a stunning statement unto itself – he shockingly misstated the reality of Health Savings Accounts (HSAs). Dr. Cassidy knew that a Kaiser Family Foundation study showed that because the HSA program provides an affordable health insurance alternative, 27% of new HSA participants were previously uninsured. Just think what might happen if HSAs were widely known and encouraged by the government.

But what seems to upset Dr. Cassidy the most is that the legislation does not address the largest problem with the health care system. He believes the system needs to be changed from a volume-based to a value-based system. The system has come to this gradually over the last 45 years as government has become more in involved in health care decisions. Doctors today need to treat huge numbers of patients to generate enough revenue to cover their costs. They often don’t have the ability to properly focus on their patients’ needs and may prematurely kick their patient to a specialist or order costly tests. The value-based system that Dr. Cassidy envisions would create greater synergy between doctor and patient, reduce malpractice costs, and provide higher quality service. Unfortunately, Obamacare will force doctors to see even more patients – thereby reducing individual attention even further – because it cuts physician reimbursements to the bone.

The largest single challenge centers on how to pay for the plan. The Democrats propose that everyone be required to carry insurance. They blithely assume that everyone will happily buy expensive insurance to subsidize those who have pre-existing conditions. Welcome to Dreamland; there’s no way that healthy young Americans will incur these huge costs, even with the threat of harsh (but obviously unenforceable) penalties.

Republicans have offered a far more palatable solution. Instead of arm-twisting middle-class Americans, Republicans propose to focus subsidizes on the limited market of individuals with medical challenges, and allow everyone else to buy competitively-priced products.

Dr. Cassidy is one of less than 20 health professionals in Congress able to offer realistic solutions based on their first-hand experience within the health system, but unfortunately, their sensible solutions have fallen on deaf ears. Perhaps the spider that Ms. Pelosi was speaking about had a venomous bite that has driven her to push these disastrous policies. God willing, her colleagues will listen to Dr. Cassidy and the American people.

But complaints are usually responded to by bureaucratic coverups and there are no apparent changes

For 12 months, while her son Kane underwent treatment for cancer, Rita Cronin sat by her youngest child's bedside. She fed him, gave him drinks, washed him and ensured he had a bedpan. And if Rita was unable to be there, husband Peter, daughter Emma or other son Matthew would take over the nursing duties.

'We'd learnt, quickly, that if we didn't carry out his basic care then we couldn't rely on the nurses to do so,' says Rita, 50, a civil servant from Balham, South-West London. 'It wasn't just Kane who was affected. We saw buzzers being left out of reach and patients missing meals, as no one had the time to feed them. 'The attitude was that patients had to wait. That nurses had other, more important, things to do. The more you asked for things, the more irritated they seemed to become. The night nurses were the worst - they were always "too busy" even to bring a bedpan. But the day ones were often unhelpful, too.'

St George's hospital, in Tooting, where Kane was a patient, 'is an award-winning hospital, yet we may as well have been in a third-world country for the nursing care my son got,' says Rita.

Strong words, but Rita is, tragically, qualified to say them. For three days after being admitted to the hospital for a hip replacement, her 22-year-old son was dead from dehydration. Kane had suffered brain cancer - while treatment was successful, the chemotherapy and radiotherapy had weakened his bones, causing him to the need the surgery. The cancer had affected his pituitary gland, which regulates the body's mechanisms, such as hydration. So, Kane was on desmopressin, medication to control the flow of fluid in his body. We later discovered that the day Kane was admitted in to hospital was the last time he took desmopressin,' says Rita.

Following his hip operation, a routine test showed Kane's sodium levels were high; his fluid levels were out of balance. A ward nurse was told this by the hospital lab, but she went off duty without sorting out treatment. He began begging for water. When his requests were turned down he became - understandably - aggressive. Inexplicably, instead of reading his notes which would have indicated the problem, nurses called security staff who restrained him.

An increasingly desperate Kane then rang the police and begged for help to get a drink. The police turned up, but were sent away by nurses who reassured them Kane was confused.

By the time Rita went to see him before work the next day, it was clear her son was very ill. 'The night nurse was standing outside the room handing over to the day nurse and I said I thought Kane was really ill,' she says. 'It was clear she thought I was being neurotic and said he was fine.'

It wasn't until the ward doctor appeared on his rounds, nearly 15 minutes later, that suddenly everything changed. He took one look at Kane and quickly called for help.'

The post mortem revealed Kane had died from dehydration. Rita has other ideas, and so, it seems, does the coroner who adjourned the inquest, calling the police in to investigate.

'Kane died because of sheer incompetence of the nurses who failed to do their job,' says Rita. 'I found out later that the nurses were offered counselling. They should have been in another job.'

Over the past few years there have been far too many similar accounts. Despite all the money poured into the NHS, and the proliferation of training, job titles and initiatives, it seems patient experience is not improving. Poor nursing care was a key factor in the 400 deaths at Mid Staffordshire NHS Foundation Trust, according to the recent official investigation. Staff numbers were allowed to fall 'dangerously low', causing nurses to neglect the most basic care. While many staff did their best, others showed a disturbing lack of compassion to patients, said Robert Francis QC, heading the inquiry.

Basic nursing care and lack of hygiene have also been blamed for 70 deaths at Basildon University Hospital, where the Care Quality Commission, the health service regulator, found, among other basic failings, blood-splattered equipment and patients lying on stained and soiled mattresses.

And statistics would suggest they are not one-offs. Complaints about nurses have risen by 18.9per cent in the past year, according to the Nursing and Midwifery Council (NMC) , the profession's regulatory body. Although the organisation points out that this figure represents just 0.2 per cent of their total membership, the fact is complaints investigated by them have risen by 30 per cent since 2005.

Experts think the problem is actually far more endemic than even these figures suggest, as many people don't know about the NMC - and instead complain through the hospital system. 'Even then, many incidents are not investigated properly,' says Vanessa Bourne, of the Patients' Association. 'Answers to complaints generally fall into one of two categories; either the letter will say: "You haven't been able to name the nurses responsible so we can't investigate". Or, "you have named the nurses responsible, but they deny any wrong-doing, so we can't take the investigation further".

'The NHS managers and nursing bodies like to say this poor treatment is from a minority of nurses, but it is more about a fundamental lack of decent nursing leadership and a refusal to admit that mistakes are being made. 'When the Staffordshire scandal broke last year, we were inundated with a deluge of heartbreaking cases where people had received careless, sloppy or even rude and cruel treatment at hospitals up and down the country, and where no investigation had ever been carried out. 'The Department of Health bring out endless guidelines and initiatives on patient satisfaction and safety, but our complaint rate doesn't drop.'

Nurses themselves are also concerned about levels of care. A recent survey for the Nursing Times found that only a third of nurses were confident the poor standards at Mid Staffordshire weren't being repeated to some degree in their own hospitals.

Last week, the government published the first comprehensive report on the profession in 40 years. The Commission into the future of nursing and midwifery made some recommendations on how nursing could be improved for the 'new challenges ahead'.

While it was initiated before the recent scandals broke, there's no doubt those events were key to its proposals. 'Events like Mid Staffs do tend to focus the mind,' says Heather Lawrence, a former nurse, now chief executive of Chelsea and Westminster Hospital and a member of the commission. 'And I would agree that in some areas of the country - not all - patient trust has been eroded. As a result there has now been an acceptance within the NHS that the way some wards have been managed has not always been in the patients' best interests.'

In order to help restore patient trust, the Commission wants all nurses to pledge their "commitment to society and service users... to give high-quality care to all and tackle unacceptable variations in standards". 'The Commission is clear that high-quality, safe and compassionate care must rise to the top of the agenda for a 21st-century worldclass NHS,' said health minister and commission chair Ann Keen.

It begs the question: if high-quality, safe and compassionate care is not a priority for some nurses, why are they nursing at all? 'We welcome the pledge, but it is a sad indictment that there is a need for one in the first place,' says Vanessa Bourne. 'Patients should expect compassion.'

'The bottom line is that in Mid Staffs - - and we believe in many other hospitals, still - - there was a culture of nurses saying "its not my job". But if everyone says that, then the job - whether it's feeding a patient, or getting them a bed pan simply doesn't get done. 'Nursing is about rolling up your sleeves and caring and too many nurses seem to forget that. 'Our response would be that if you don't want to do the nitty-gritty of spoon-feeding an elderly patient or changing soiled sheets, then don't go into nursing.

'Employers also have to accept that not everyone who comes into nursing will be cut out for the job. I was told by a university nursing tutor that some trainees on her course who were clearly not suited to nursing and not interested in caring, but it was impossible to remove them because of funding complications.

So what is the solution? The official response is that we need better leadership - giving ward sisters more authority. 'One of the things we found was that on many wards there was no one figure who had the authority to properly lead the ward,' says Heather Lawrence. 'In the Mid Staffs inquiry it was discovered that one nursing sister was in charge for three wards - an impossible task.'

Nurses acknowledge leadership is part of the problem; and the solution. The Nursing Standard magazine (the nurse's own trade magazine) is campaigning to boost the authority and status of ward sisters. 'All these NHS scandals have a common theme,' says editor Graham Scott. 'There was not a clear, identifiable person in charge of the ward. 'We have ward sisters, specialist nurses and nurse specialists, nurse consultants and modern-day matrons. No wonder people get confused about who is in charge.'

But will such a simple solution make the wards a better and safer place for patients? According to Graham Scott, it will. 'Research shows that on a ward where there is an identifiable - and, most importantly, accountable - person in charge, patients have a much better experience,' he says.

The finger of blame is also being pointed at healthcare assistants, who do the basic caring jobs, such as washing, feeding and changing bedpans. 'Some NHS Trusts do train nursing assistants properly,' explains Graham Scott. Others don't. Cleaning, washing and feeding a patient are actually quite complex tasks.'

The Commission recommended these staff need some form of regulation to ensure high-quality care. 'We have to be careful about blaming the healthcare assistants,' says Bourne. 'After all, they are supposed to be supervised by the nurses.'

But will any of this make a real --difference? It seems there will be no legal recommendations to abide by the regulations. 'We do tend to raise our eyebrows at these recommendations,' notes Bourne. 'There is a big noise about them, and then everything goes back to how it was. We still get horror stories like poor Kane's. We are told things will change and they don't.'

Indeed St George's has told Rita Cronin they've made changes to ensure what happened to her son can never happen again. 'But what exactly are these changes?' she asks. 'My son suffered a needless death. How I do know that the same thing isn't happening to someone else?'

A spokesman for the hospital said: "We are extremely sorry about the death of Kane Gorny. 'From the investigation it was clear that there had been failures in communication between clinical staff. Disciplinary action did result from our findings and a number of important changes have been introduced to help prevent such a tragic incident from happening again.'

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Background

Postings from Brisbane, Australia by John Ray (M.A.; Ph.D.) -- former member of the Australia-Soviet Friendship Society, former anarcho-capitalist and former member of the British Conservative party.

This blog gives a lot of attention to events in Australia and Britain -- places where there already exist systems similar to the one most likely to befall the USA if the Democrats get their way -- "Free" medical care supposedly available to all through government hospitals but with a competing private sector as well. The Canadian system is considered too Soviet to provide a likely model for the USA

TERMINOLOGY: Many of my posts concern the very instructive state of socialized medicine in Australia. Like the USA, Germany and India, Australia has a system of State governments which have substantial independence from the central (Federal) government and it is they who are mainly responsible for "free" health services. It may therefore be useful to some for me to note the standard abbreviations for the States concerned: QLD (Queensland), NSW (New South Wales), WA (Western Australia), VIC (Victoria), TAS (Tasmania), SA (South Australia).

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Conservatives do NOT object to helping the poor. Government welfare legislation in aid of the poor was in fact first introduced by conservatives -- Bismarck and Disraeli in the 19th century. What conservatives want is for the help to be delivered in a sane manner. And anyone who thinks that government bureaucracies can run hospitals well is completely out of touch with reality.

One of the oldest "free" public hospital systems in the world is that in the Australian State where I live: Queensland. It dates from 1944 (Britain's NHS began in 1948). So its advanced state of decay reveals well where the slow cancer of bureaucracy ends up. It now has three "administrative" employees for every medical employee. All those clerks are really good at curing people, I guess! Frequent bulletins on the flailing but ineffectual attempts to "fix" the system will appear here -- as well as bulletins on the dreadful things it does to patients and the long waits they endure.

On all my blogs, I express my view of what is important primarily by the readings that I select for posting. I do however on occasions add personal comments in italicized form at the beginning of an article.

I am rather pleased to report that I am a lifelong conservative. Out of intellectual curiosity, I did in my youth join organizations from right across the political spectrum so I am certainly not closed-minded and am very familiar with the full spectrum of political thinking. Nonetheless, I did not have to undergo the lurch from Left to Right that so many people undergo. At age 13 I used my pocket-money to subscribe to the "Reader's Digest" -- the main conservative organ available in small town Australia of the 1950s. I have learnt much since but am pleased and amused to note that history has since confirmed most of what I thought at that early age.

I imagine that the the RD is still sending mailouts to my 1950s address!

NOTE: The archives provided by blogspot below are rather inconvenient. They break each month up into small bits. If you want to scan whole months at a time, the backup archives will suit better. See here or here